About the Facility
- CMS Certification Number (CCN)
- 10T173
- Ownership Type
- Non-profit
- CMS Region
- Atlanta
- Certification Date
- Address
3100 East Fletcher Avenue
- Phone Number
- (813) 615-7200
Facility Medical Condition Statistics
- All other conditions
- 137
- Brain disease or condition (non-traumatic)
- 55
- Brain injury (traumatic)
- 24
- Hip or femur fracture
- 30
- Hip or knee replacement, amputation or other bone or joint condition
- 54
- Nervous system disorder (excluding stroke)
- 13
- Spinal cord disease or condition (non-traumatic)
- 13
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 97
Facility Quality of Patient Care Measures
- Catheter-associated urinary tract infections (CAUTI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- Not Available
- SIR 95% confidence interval - upper limit
- Not Available
- Comparative performance category
- Not Available
- Catheter days
- 381
- Predicted number of infections (B)
- 0.876
- Number of infections reported (A)
- 0
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 427
- Denominator
- 427
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 11.1
- Denominator
- 358
- Average observed change score
- 12.2
- Change in patients ability to move around
- Average risk-adjusted change score
- 26.6
- Denominator
- 358
- Average observed change score
- 28.8
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 166
- Denominator
- 358
- Facility rate
- 46.4
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 149
- Denominator
- 358
- Facility rate
- 41.6
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 1
- Denominator
- 427
- Facility rate
- 0.2
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.015
- SIR 95% confidence interval - upper limit
- 1.481
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 7,827
- Predicted number of infections (B)
- 3.331
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.300
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 76
- Number of health care workers
- 134
- Rate of flu vaccination
- 56.7
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 39
- Number of eligible stays
- 382
- Unadjusted potentially preventable readmission rate
- 10.21
- Risk-standardized potentially preventable readmission rate (RSRR)
- 9.00
- Lower limit of the 95% confidence interval on the RSRR
- 7.37
- Upper limit of the 95% confidence interval on the RSRR
- 11.12
- Comparative performance category
- No Different than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 16
- Number of eligible stays
- 429
- Unadjusted potentially preventable readmission rate
- 3.73
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.10
- Lower limit of the 95% confidence interval on the RSRR
- 3.13
- Upper limit of the 95% confidence interval on the RSRR
- 5.67
- Comparative performance category
- No Different than the National Rate
- Rate of successful return to home or community from an IRF
- Observed number of discharges to community (DTC)
- 215
- Number of eligible stays
- 325
- Observed discharge to community rate
- 66.15
- Risk-standardized discharge to community rate
- 67.78
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 63.25
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 72.34
- Comparative performance category
- No Different than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 0.98
- Number of eligible episodes
- 370
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 416
- Denominator
- 427
- Facility rate
- 97.4
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 8
- Denominator
- 426
- Facility observed rate
- 1.9
- Facility risk-adjusted rate
- 2.3
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 72
- Number of health care workers
- 88
- Rate of COVID-19 vaccination
- 81.8